Diagnostic dilemma in post-abortion intrauterine retention: endometrial polyps mimicking retained products of conception

Serum β-HCG Level in Women Diagnosed as Having Retained Products Of Conception: A Prospective Cohort Study

Feasibility of Office-Based Operative Hysteroscopy by a Tissue Removal System Without Anesthesia

Data of 101 patients with retained products of conception (RPOC), treated with office hysteroscopy (OH) from 2012 to 2015 at the University Medical Centre Ljubljana were analysed. Patients with >30 mm RPOC thickness or strong vascularisation on ultrasound (US) were excluded. Procedures were successfully completed in 94/101 (93%). Mean duration was 18 min (4–60), patient pain estimation with VAS was 2.3 (0–8). No intraoperative complications > Grade II according to Clavien-Dindo classification occurred. Uncompleted cases were safely referred to procedures in general anaesthesia. Follow-up after one month was performed in 78/101 (77%) patients with OH (69) or US (9). Only three patients reported endometritis, three cases of intrauterine adhesions were related to curettage or pre-existing adhesions. We compared preoperative findings of completed and uncompleted cases. Larger size of RPOC and the presence of irregular tissue-myometrial border on US was statistically significantly higher in uncompleted OH (p<.05); mild vascularisation and β-hCG levels up to 80 U/L did not affect the outcome.Impact statementWhat is already known on this subject? In the last three decades research has focussed on comparing hysteroscopic resection (HR) to traditional dilation and curettage in removing retained products of conception (RPOC). Office hysteroscopy (OH) without hospitalisation or general anaesthesia enables women to return to their daily routine immediately (especially desired by breastfeeding mothers) and is used where available, yet there is little published data to evaluate its role in the management of RPOC.What do the results of this study add? To the best of our knowledge, this article is unique in addressing success, safety and possible limiting factors of OH in removing placental polyps. According to our findings, OH is highly successful (93%), safe, and well tolerated in removing RPOC up to 30 mm in thickness and with no or minimal vascularisation on ultrasound. Thorough follow-up (68% with OH, 9% with US after 1 month) adds to strength of data.What are the implications of these findings for clinical practice and/or further research? Removing large and vascularised RPOC can be a very demanding procedure, yet a majority of patients might benefit from an outpatient approach. Prospective studies on limiting factors and more data on long term reproductive outcomes are needed to fully compare OH to other methods of removal.

Purpose: To investigate the ultrasonic characteristics of endometrial polyps in breast cancer patients after anti-estrogen endocrine therapy. Methods: A total of 91 patients with endometrial polyps who had breast cancer surgery at Yantai Muping District Hospital of Traditional Chinese Medicine, Yantai, China between February 2021 and August 2023 were randomly assigned to study (n = 42) and control groups (n = 49) based on post-surgery anti-estrogen endocrine therapy. The study group received tamoxifen (20 mg orally once daily for 6 months). Control group did not receive any post-surgery anti-estrogen endocrine therapy. Ultrasound characteristics of the study and control groups were assessed and compared. Results: The study group exhibited significantly increased endometrial thickness compared to control group (p &lt; 0.05). However, both maximum and mean polyp diameters were significantly larger in the study group (p &lt; 0.05). Linear endometrial echoes predominated in treated patients, contrasting with predominantly uniform echoes in the control group. Visualization issues of the uterine cavity line were significantly more common in the study group, while control group experienced more deviation and unclear visualization. Also, the study group mostly presented with strip-shaped polyps, differing from the round or oval shapes prevalent in control group. Furthermore, there were significant variations in internal echo characteristics and blood flow parameters between the two groups (p &lt; 0.05). Conclusion: Endometrial polyps caused by postoperative anti-estrogen endocrine therapy in patients with breast cancer have unique ultrasonic characteristics, good ultrasonic diagnostic effect and a high detection rate as long as it is detected early and treated on time. Further analyses are needed with a larger sample size to investigate the underlying mechanism involved in developing endometrial polyps.

The aim of this study was to compare office to conventional operative hysteroscopy for the treatment of retained products of conception (RPOC). This retrospective cohort study included all women who underwent hysteroscopy due to RPOC between January 2018 and December 2019, in a single tertiary medical care center. Exclusion criteria for hysteroscopy included the following: (1) proximity to delivery (up to 3weeks); (2) hemodynamic instability; (3) active massive bleeding; and (4) genital tract infection. See-and-treat hysteroscopy (study group) outcomes were compared to operative hysteroscopy (controls). Data were collected from women's medical records. Primary outcome was defined as successful removal of all suspected RPOC with no need for additional intervention. Data are presented as median and interquartile range. During the study period, 222 women underwent hysteroscopy due to RPOC. Of them, 138 (62%) and 84 (38%) underwent see-and-treat and operative hysteroscopy, respectively. Symptomatic women were more commonly referred to operative hysteroscopy (60 (71%) vs. 54 (39%); p = 0.001). Maximal diameter of the suspected finding was smaller both by ultrasound examination (13 (10-18) vs. 18 (13-32) mm; p = 0.001) and by surgeon estimation during diagnostic hysteroscopy (12 (8-20) vs. 20 (14-30) mm; p = 0.001), in the see-and-treat compared to the operative hysteroscopy group, respectively. While comparing success rate between groups, no difference was observed. Sub-analysis by the maximal diameter of RPOC findings revealed that see-and-treat success rate is reduced as the RPOC is larger. Success rate was high and comparable to operative hysteroscopy for findings ≤ 2cm (102/117 (87%) vs. 49/54 (91%); p = 0.79). Nevertheless, for RPOC > 2cm, success was significantly more frequent in the operative hysteroscopy group (28/30 (93%) vs. 9/16 (57%); p = 0.002). This finding was supported by logistic regression analysis that found maximal diameter of RPOC as the only parameter associated with success rate (B = 0.96; p = 0.03). Office operative hysteroscopy is a feasible treatment option for the removal of RPOC when maximal diameter is taken under consideration due to its association to success rate.Clinical trial registration: The study protocol was approved by the "Sheba Medical Center" Review Board (ID 5200-18 SMC) on June 24, 2018.

Missed abortion can be treated with medication or aspiration curettage. A Karman aspiration cannula is another option. We evaluated its success in evacuating retained products of conception (RPOC) based on symptoms, endometrial thickness, endometrial irregularity, and blood flow seen on Doppler ultrasound (indicative of placenta). This prospective, randomized, nonblinded trial was conducted in a university-affiliated medical center. It included 40 women diagnosed with missed abortion and two failed courses of 600µg buccal misoprostol, one week apart, randomly assigned to treatment or controls. One week after the second misoprostol course, immediately after evaluating endometrial thickness, endometrial irregularity using Doppler ultrasound, and with blood flow indicative of RPOC, women in the aspiration group underwent endometrial suction with a Karman aspiration cannula. The 5-6mm cannula attached to a 60mL syringe was inserted into the uterus under ultrasound guidance. The contents were aspirated until the uterus was empty. Control group patients did not receive additional treatment. All were scheduled for ambulatory, operative hysteroscopy under anesthesia 1month later (departmental protocol). On that day, all women with RPOC on Doppler ultrasound underwent hysteroscopy. Bleeding days, days with pain, pain according to visual analog scale, length of hospitalization, and infection rate were recorded. NIH clinical trial registration number NCT02917785. In the study group, 90% did not need hysteroscopy, compared with 50% of controls (p=0.014). No complications were noted. At all visits, we used Doppler ultrasound to exclude or confirm RPOC. Pathology revealed RPOC in all women who underwent aspiration. Average visual analog scale score for office aspiration (n=20) was 4.9±3.6. vs. 6.3±3.4 for the first (p=0.157) and 4.7±3.3 for the second (p=0.836) misoprostol treatment cycle. The treatment group experienced 6.1days of bleeding and the control group experienced 1.4days (p=.006). Based on our criteria of diagnosing RPOC according to symptoms, endometrial thickness, endometrial irregularity, and blood flow indicative of placental tissue seen on Doppler ultrasound and histo-pathological confirmation, aspiration using Karman cannula can be an effective therapeutic approach. It may be a safe alternative for women with RPOC after misoprostol failure.

The use of the 19Fr. Intrauterine BIGATTI Shaver in operative hysteroscopy for benign intracavitary lesions: A feasibility study.

High prevalence of endometrial polyps in endometriosis-associated infertility

Endometrium from women with endometriosis shows increased proliferation activity

The interpretation of postpartum and postabortion uterine abnormalities on sonography can be challenging. The purpose of this study was to identify misleading imaging features that lead to inclusion of a uterine arteriovenous malformation (AVM) in the differential diagnosis of a uterine abnormality because consideration of this diagnosis can potentially alter patient treatment. The sonographic examinations of 29 pathologically proven cases of uterine abnormalities in postpartum and postabortion patients were retrospectively reviewed. Two radiologists independently evaluated several features: the presence of a uterine mass, myometrial involvement, and the presence of an associated vascular abnormality. Percent agreement and the relationship between imaging features and inclusion of a uterine AVM in the differential diagnosis were determined. Interobserver agreement was as follows: the presence of a uterine mass, 90%; myometrial involvement, 83%; the presence of an associated vascular abnormality, 72%; and inclusion of a uterine AVM in the differential diagnosis, 86%. Myometrial involvement showed a statistically significant relationship to inclusion of a uterine AVM in the differential diagnosis (P < .05). Final pathologic diagnoses included retained products of conception (RPOC) (n = 26), an endometrial polyp (n = 1), chronic endometritis (n = 1), and an exogenous progestational effect (n = 1). No uterine AVMs were found. Despite high interobserver agreement in characterizing uterine abnormalities on sonography, readers still include uterine AVMs in the differential diagnosis of uterine masses that are ultimately proven to be RPOC. A myometrial location of a uterine mass is a particularly misleading imaging feature of RPOC.

Objective To detect the expression of vascular endothelial growth factor (VEGF) in endometrial polyps (EP), to explore its mechanism based on the mechanism of angiogenesis, and to provide experimental evidence for clinical treatment. Methods 30 patients pathologically confirmed as EP who underwent hysteroscopic resection of EP in our hospital from June 2015 to June 2016 were selected as the study group, and 30 patients who underwent hysteroscopy because of infertility and pathologically confirmed as normal endometrium during the same period were selected as the control group. The expression of VEGF in EP tissue and adjacent zone to the EP of the study group, and control group were measured by immunohistochemistry. The study group was treated with drospirenone and ethinylestradiol for 3 cycles, and then the expression of VEGF in the endometrium was detected again. Results The positive expression rate of VEGF: EP tissue (73.33%) > adjacent zone to the EP (46.67%) > normal endometrium (20.00%) (P<0.05). After 3 cycles of COC treatment, the positive expression rate of VEGF in adjacent zone to the EP of EP patients was down-regulated from 46.67% to 16.67% (P<0.05). Conclusions Increased expression of VEGF leading to increased microvascular angiogenesis may be one of the reasons of the formation of EP. COC treatment can reduce the expression of VEGF in endometrial tissue, and thus has a certain role in preventing relapse of EP. Key words: Endometrial polyp; Vascular endothelial growth factor; Oral contraceptive

The aim of research: To study the pathomorphological and endoscopic features of endometrial polyps in women of reproductive, premenopausal and postmenopausal age and conduct a comparative analysis.Materials and methods. To carry out the planned study, 116 women with endometrial polyps were included, who were treated at the Women’s Medical Center of Clinical Hospital “Feofania”. Depending on the pathomorphological type of endometrial polyposis, four groups of patients were formed, Group 1 - 34 women with glandular endometrial polyp, group 2 - 32 patients with glandular-fibrous endometrial polyp, group 3 included 34 women with endometrial fibrous polyp, and the fourth group - 16 patients with endometrial adenomatous polyps. Diagnostic search was carried out by ultrasound followed by hysterectectoscopy and histological examination.Results and discussion. Glandular and glandular-fibrous polyps of the endometrium showed predominantly in women of reproductive 15 (39.4%) age and 10 (31.1%) patients of premenopausal age, against the background of simple endometrial hyperplasia without atypia, in 21 (61.7%) women and in 13 (38.2%) cases against the background of unchanged endometrium. Fibrous polyps are characteristic of postmenopausal women in 21 (45.6%) cases, while on the background of atrophic endometrium in 22 (64.7%) patients, in 7 (20.5%) patients on the background of simple endometrial hyperplasia without atypia, in 5 ( 14.7%) cases against the background of unchanged endometrium. Adenomatous polyps of the endometrium were found in 16 (13.7%) patients of them reproductive 5 (13.1%) and 6 (18.7%) cases of premenopausal age, against the background of complex endometrial hyperplasia without atypia in 5 (31.2%) patients, in 4 (25.1%) women on the background of simple endometrial hyperplasia with atypia, as well as in 3 (18.8%) patients on the background of complex adenomatous endometrial hyperplasia with atypia, and in 1 (6.25%) case on the background atrophic endometrium.Conclusions. Glandular and glandular fibrous polyps of the endometrium are characteristic mainly for women of reproductive and premenopausal age, fibrous polyps of the endometrium are mainly manifested in patients of postmenopausal age. Adenomatous polyps of the endometrium are observed in all age groups. A study of the pathomorphological and endoscopic features of endometrial polyps in women of different age categories in the background endometrium and polyp tissue makes it clear that in most cases they have different pathomorphological characteristics (93,3%), it makes sense to use hysteroscopy with targeted sampling with separate marking of histological material with the definition of further tactics for managing patients for results of pathomorphological findings.

To assess the incidence of retained products of conception (RPOC) in relation to transvaginal ultrasound performed after first-trimester uterine evacuation. This was a prospective randomized study involving 809 women undergoing first-trimester uterine evacuation. The study group included 404 women in whom transvaginal sonography was performed at the end of the surgical procedure and the control group contained 405 women who did not undergo ultrasound examination. Initially, in the study group, recurettage was immediately performed if the endometrium appeared irregular but latterly only if endometrial thickness was > or = 8 mm. The patients were followed up by gynecological and ultrasound examinations 5-8 days following the surgical procedure. The total complication rate was 4.3%. RPOC presented in three women in the study group (0.7%) and in 15 women in the control group (3.7%, P < 0.05). Vaginal bleeding requiring hospitalization occurred in two women in the study group (0.5%) vs. seven in the control group (1.7%, P = 0.2). Endometritis was diagnosed in one woman in the study group (0.2%) vs. six in the control group (1.5%) and uterine perforation occurred in one woman in the control group vs. none in the study group. There were no cases of RPOC in women who had an endometrial thickness of < 8 mm as demonstrated by ultrasound at the end of the surgical procedure. Transvaginal sonography immediately following first-trimester uterine evacuation may reduce the incidence of RPOC and the total complication rate. When the endometrial thickness is > or = 8 mm at the end of suction curettage, an attempt at re-evacuation of the uterine cavity is indicated.

Endometrial polyps are benign focal overgrowths of the uterine mucosa. They are a recognized cause of abnormal vaginal bleeding and have also been associated with subfertility and early pregnancy loss1,2. The ultrasound features of benign polyps in non-pregnant women have been well-documented3, but there have so far been no reports of endometrial polyps identified on ultrasound examination during early pregnancy. In this report, we describe 10 cases of endometrial polyps diagnosed in the first trimester and followed-up during pregnancy (Table 1). In nine women (Cases 1–9), a solid hyperechoic structure was seen protruding into the uterine cavity adjacent to the gestational sac on the first scan (Figure 1). In the remaining case (Case 10), the polyp was first diagnosed at a follow-up examination at 12 weeks. It was located below the placenta with a well-defined feeder vessel. In nine cases, the polyp had an appearance typical of a benign lesion. One polyp (Case 3) appeared as a cystic structure adjacent to the gestational sac, which was suspected initially to be a complete hydatidiform mole (Figure 2). Serum beta-human chorionic gonadotropin (β-hCG) level at 13 weeks' gestation was 179 233 IU/L or 2.5 multiples of the median. Maternal serum β-hCG levels decreased between 13 and 20 weeks, whereas the focal cystic structure remained of similar size at the periphery of the placenta. Blood supply to the lesion decreased after 13 weeks and the final diagnosis of an endometrial polyp was made. In two cases (Cases 3 and 10), the polyp was identified at birth attached to the placental membranes, and their benign nature was confirmed on histopathological examination. We also compared the size of the endometrial polyps in pregnancy to the findings obtained in a cohort of 41 randomly selected premenopausal non-pregnant women with endometrial polyps. The median diameter of the polyps detected in pregnancy was 14.7 (interquartile range (IQR), 9.0–23.4) mm, which was significantly larger compared with the 7.3 (IQR 5.5–10.4) mm in non-pregnant women (Z-score, −3.440; P = 0.0006). Our case series shows that some endometrial polyps can be detected on ultrasound examination during the first trimester of pregnancy. This is a novel observation and we have not found any previous reports in the literature describing ultrasound diagnosis of endometrial polyps in early pregnancy. Differential diagnosis of a focal lesion in the endometrial cavity during early pregnancy includes submucous uterine fibroids, focal adenomyosis, ‘chorionic bump’4, multiple pregnancy combining a normal gestational sac with retained products of conception, or a complete hydatidiform mole. The other possible rare diagnosis is mesenchymal dysplasia of the placenta. We found that five of nine women in our series who wished to continue with their pregnancy had a healthy baby at term. This finding supports the view that endometrial polyps may not be associated with impaired implantation and placentation, and are not a major risk factor for early pregnancy failure or subsequent placental insufficiency5. Women should be advised that their pregnancy could develop normally despite the presence of a polyp and that they should continue with their routine antenatal care. A follow-up scan may be arranged once the pregnancy is completed to check for their presence and consider surgical removal.

Sublingual misoprostol after surgical management of early termination of pregnancy